1407396286 NPI number — INTENTIONAL GROWTH LLC

Table of content: (NPI 1407396286)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407396286 NPI number — INTENTIONAL GROWTH LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INTENTIONAL GROWTH LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1407396286
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/20/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5360 HOLIDAY TER
Provider Second Line Business Mailing Address:
SUITE 18
Provider Business Mailing Address City Name:
KALAMAZOO
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49009-2126
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
269-447-1211
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5360 HOLIDAY TER
Provider Second Line Business Practice Location Address:
SUITE 18
Provider Business Practice Location Address City Name:
KALAMAZOO
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49009-2126
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-760-6236
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/28/2017

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
THOMAS
Authorized Official First Name:
MARNIE
Authorized Official Middle Name:
SUE
Authorized Official Title or Position:
MANAGING MEMBER
Authorized Official Telephone Number:
269-447-1211

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  6401012521 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)